Assessing Hypermobility

Assessment starts when the client walks in the door. Look for a loose-limbed gait or a tendency to turn the body by lateral rotation at the hip rather than through the spine. The loosened ligaments that allow a fallen arch may have loosened counterparts elsewhere in the body.

Tall, thin people are more likely than others to be hypermobile; indeed, one of the Marfan Syndrome’s five characteristic signs is long, slender limbs, digits, and torso. When taking the client’s history, look for a pattern of joint dislocations, especially one that involves multiple joints. Look also for other indications that may implicate connective tissue, such as heart-valve problems and generalized joint pain.

Visual assessment continues when the client is on the table. Note if the sternum is displaced, either anteriorly or posteriorly; costal cartilage may be loose, too. Look for signs of bruising or unusually loose skin. More to the point, of course, take note of range of motion (ROM) at each joint. Hypermobility at one joint on one side is likely to come from injury or repetitive motion at that joint. Bilateral hypermobility at multiple joints indicates a systemic cause. If you see evidence of the latter, you might tell the client that hypermobility is not necessarily a sign of anything wrong but that her primary health care provider might want to know about it.

In general, beware of stretching an already hypermobile joint. By definition, it is loose enough already. The best way to address a hypermobile joint is to strengthen its supporting musculature. Further stretching may damage fragile connective tissue or endanger an unstable mechanical linkage. Thus, a client with a hypermobile wrist or knee should be taught ways to strengthen the relevant flexors and extensors.

However, sometimes (as in trigger-point work) one must stretch a muscle that is adjacent to a hypermobile joint. The optimal stretch form depends on the muscle’s size and kinesiology. A two-joint muscle often will require movement at both joints. For example, (see Figure 1, a and b), the most widely used stretch for quadriceps femoris flexes the knee to bring the ankle towards the buttock. However, one can often flex a hypermobile knee until calf meets thigh without eliciting a satisfactory response from the quadriceps. The solution is to flex the knee and hyperextend the hip at the same time (Figure 1c), putting the quadriceps under tension but minimizing stress on both joints.

• The V: Grasp the belly of the muscle at the midpoint and move it perpendicular to the direction of tension. This form stretches the entire muscle and both attachments at the same time.

• The Z: Grasp the muscle belly at two separated points along its length. Move the points in opposite directions perpendicular to the direction of tension. This form produces a more intense stretch than the V, but is difficult with small or deep muscles.

• The Pin: Grasp the belly of the muscle at the midpoint and hold it immobile with respect to one bone while moving the joint through the rest of its ROM. This form stretches only one attachment tendon and its portion of the muscle. However, you can affect both halves of the muscle by alternating which half stays immobile.

• The Strip: Grasp the belly of the muscle with both hands near the midpoint. Stretch the muscle between the hands while moving them towards the two attachments. This form (when done carefully) affects only the central part of the muscle and places little stress on the tendons and the joint capsule.

Sacroiliac Joint

The sacroiliac joint (SIJ) provides a useful example of hypermobility considerations. The SIJ has fibrous ligaments and a limited ROM, like a typical amphiarthrosis, but its condylar articular surfaces and synovial capsule fit the definition of a diarthrosis.² Its articulations allow the sacrum to rotate in its own plane, and also in the sagittal plane ("nutation"). There is also a small amount of lateral and vertical sliding play. If the SIJ’s connective tissues feel loose, then these motions can be extensive enough to activate local proprioceptors and generate pain.

Unlike most of the rest of the body’s joints, the SIJ is not stabilized by any single-joint muscle. Other than its ligaments, the SIJ depends on a collection of multi-joint muscles: the piriformis-gemellus-obturator group, gluteus maximus, and portions of erector spinae by way of the thoracolumbar aponeurosis. None of these muscles is devoted to maintaining the sacrum in proper position relative to the pelvis. Each of them can, if strongly involved in moving its other joint, pull the sacrum out of its proper alignment with the spine, the pelvis, and the force of gravity.